Dhat Syndrome: Sexual Behaviour and Psychiatric Comorbidity

Original Research Article

Title: Dhat syndrome and its association with sexual behavior and pyschiatric comorbidities in Indian males

Sahu R.N, MD (Psychiatry), Head and Professor,

Co- Authors:

1. Sharma V K, MD, WHO Fellow (USA), Head and Professor, Department of Medicine Gandhi Medical College, Bhopal, Madhya Pradesh, India
2. Ashutosh Kumar, Lecturer, Gandhi Medical College, Bhopal, Madhya Pradesh, India
3. Chintan Bavishi, Lecturer, Manipal University, Manipal, Karnataka, India
4. Balaji More, Assistant Professor, Krishna Institute of Medical Sciences, Karad, Maharashtra

Title: Dhat syndrome and its association with symptoms, sexual behavior and comorbidities in Indian male patients


Abstract:

The Context (Background): Dhat syndrome is often taken as culture bound syndrome of Indian subcontinent. There are many misconceptions which form base of symptoms and comorbidities.

Aims: Dhat syndrome is reported on basis of self diagnosis. The study aims to study associated symptoms, sexual behavior and comorbidities in Indian population.

Methods and Material: This cross-sectional and case-control study, was carried with help of trained local interviewers at Department of Psychiatry and Medicine, Gandhi Medical College (GMC), Associated Hamidia Hospital, Bhopal, India. Cases were compared to healthy matched controls. The study was conducted using clinical interview, physical examination and other necessary investigations like urine analysis and microscopy.

Results: Of the 50 cases and control, each, age group was 21 to 25 years (48%) and education upto12

^th

class (60%). 20% cases reported history of Masturbation. Extramarital or premarital sexual contact was found to have little significance on the syndrome. 76% of the patients met DSM-IV Diagnostic Criteria for Anxiety and 56% patients met for Depression. 23 patients (46.3%) were having a co-morbid somatic complains like bodyache, weakness and fatigue. Erectile dysfunction by 34% & Premature ejaculation by 8% was reported. In Urine routine analysis and microscope no oxalates or phosphates were noted.

Conclusions: Dhat syndrome is more common among low educated young population. Laboratory evidence of any pathological cause was not found. Contrary to popular belief, it had no direct correlation with masturbation and pre and extra marital sexual contact.

Key Words:

Dhat Syndrome, Semen, Sexual behavior, Somatic symptoms, Erectile Dysfunction

Introduction

Dhat syndrome is a Culture bound syndrome.

¹

But it has been mentioned in medical history and reported by population worldwide. The culture has profound impact on the mental status of an individual. According to International Classification of Diseases (ICD) – 10 had classified Dhat syndrome had been classified in both neurotic disorder (F48.8) and into culture specific disorder caused by ‘undue concern about the debilitating effects of the passage of semen.’ The cases are always self reported and they often report a set of symptoms. These vague somatic symptoms are fatigue / bodily weakness, headache, depression

³

, anxiety, loss of appetite, palpitation / tachycardia, guilt, poor concentration, forgetfulness.

²

Due to existing belief it is often associated as a result of masturbation and being sexually active outside marriage. The comorbidities include erectile dysfunction, premature ejaculation and impotence.

Patients reported semen loss in urine or involuntarily outside (spontaneously; while sleeping; during defecation; or while showering) of sexual relations.

⁴

A typical profile of Dhat Syndrome patient either is a young man, unmarried or recently married, less educated, and the one who holds strong traditional beliefs.

⁵

This category of disease involves mixed disorders of behavior, beliefs, and emotions which are of uncertain etiology and nosological status and which occur with particular frequency in certain cultures. The cultural belief and pattern associated with Dhat syndrome make it different from delusional disorder.

^{6, 7}

Material and Methods:

The study is a case-control cross sectional study, aimed to evaluate the symptoms, beliefs and comorbidities related to Dhat syndrome. The study and control group of 50 each was assessed.

The study was conducted at Gandhi Medical College (GMC), Associated Hamidia Hospital, Bhopal, India. Study group of 50 subjects was selected who had Dhat syndrome without any other organic disorder at OPD of Psychiatry Department. The control group of 50 patients was shortlisted from the Medicine Department. They were not diagnosed for Dhat syndrome and were matched with the case group in most aspects. Both groups were interviewed based on a structured interview.

Inclusion criteria:

Case group:

Complain of whitish discharge in the urine and associating it with symptoms and comorbidities

Fulfilled DSM-IV TR criteria apart

Consenting to clinical interview

Control group:

Inpatients who were not suffering from Dhat syndrome though they were suffering from other medical ailments

Matched in other aspects with the case group

Consenting to clinical interview

Exclusion criteria: Presence of

1. Genitourinary disorder
2. Testicular tumor
3. Varicocele
4. Organic sexual dysfunction
5. Pelvic inflammatory disease
6. Endocrine disorders
7. Spinal cord trauma

Ethics:

Institutional review board and ethical committee approval was taken from GMC, Bhopal, India. All periodic adverse event reports were reported to them and appropriate guidance was taken.

All interviewers were careful about ethical and legal considerations. All identification information including names, initials and hospital numbers were avoided to keep the patient details in anonymity. Written information consent after the details of the project were fully explained was obtained from all participants. There were no minors involved and hence no paternal consent involved in this study.

Statistics: The data was analyzed by using statistical tests of mean and standard deviation. (

P>0.005)

Results:

Dhat syndrome is prevalent in younger age group. Anxiety is most prevalent followed by depression. They are related to sexual symptoms as ejaculatory dysfunction, premature ejaculation and impotence. (Fig. 1) Patients associated Dhat syndrome as a direct result of excessive indulgence in sexual activity or masturbation or to nocturnal emissions. (Fig. 2) Dhat syndrome was prevalent in class of lower education, below class 12.

Routine biochemical and urine laboratory evaluation was conducted for all 100 participants.Other necessary investigations were carried out as per the requirement of the subjects to exclude organicity ( Sonography and Hormone Assay). None of the reports showed presence of oxalates or phosphates. A semen analysis founded out only 1 patient had azoospermia and 2 were having oligospermia.

Figure 1: Co-morbid conditions associated with patients in study group and control group

Figure 2: Sexual history of patients in study group and control group

Discussion

As a Culture bound syndrome, Dhat syndrome has been discussed for long time. Epidemiology and prevalence is noted in history of medicine all over the world.

^{1, 8}

The Dhat syndrome is not limited to Indian subcontinent. The origin of its name had a strong relationship with Indian culture, history and mythology.

^{9, 10}

Dhat Syndrome forms an important health problem and the magnitude is also very high. In view of this it needs a proper attention and sensitization amongst the healthcare providers for the proper treatment, counseling of these patients and referring them to related specialty. The patient presenting with Dhat syndrome is typically more likely to be recently married; of average or low socio-economic status (student, laborer or farmer by occupation), came from a rural area and belonged to a family with conservative attitudes towards sex.

¹¹

The exact pathophysiology of ‘Dhat syndrome’ is not known. The study demonstrated various other symptoms and morbidities being involved along with Dhat syndrome. The prevalence in relatively younger age group can be attributed to hormonal rush.

¹²

Majority of these individuals visited self-claimed sex specialists and traditional faith healers. The contact with these health providers not only strengthen their misconception and false beliefs, but also compel the patients to pay huge cost of investigations and drugs which are not only non-effective but also hazardous.

⁵

Among other studies the relationship between marital status or sexual contact outside marriage and Dhat syndrome is not discussed. This study establish contrary to the popular belief that no such cause-effect relationship exists. Dhat syndrome was most common among illiterate patients and less educated patients. There is a need for patient education and sex education in the eradication of syndrome.

^{13, 14}

The spread of disease in all age groups indicate towards the need of patient education about the disease in India. In many cases the syndrome is under diagnosed. In general, the deep-rooted misconceptions associated with anatomical and physiological aspects of sexuality are difficult to be correct with general counseling sessions.

The further work in this field is required to know: Whether Dhat is a Culture bound syndrome only in India? What is the pathophysiology behind it? Is there any relationship of it with depression, anxiety or other mental health disorder? Whether there is any relationship between puberty and Dhat syndrome.

Acknowledgement: We are thankful to all the interviewers who conducted data collection.

References

1. Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes: the story of Dhat syndrome. Br J Psychiatry. 2004; 184: 200-9.
2. Bhatia M.S, Jhanjee A, Kumar P. Culture bound syndromes- a cross-sectional study from India. European Psychiatry. 2011; 26:448
3. Dhikav V, Aggarwal N, Anand KS. Is Dhat syndrome, a culturally appropriate manifestation of depression? Med Hypotheses. 2007; 69 (3): 698.
4. Mehta V, De A, Balachandran C. Dhat syndrome: a reappraisal. Indian J Dermatol. 2009; 54(1): 89-90.
5. El Hamad I, Scarcella C, Pezzoli MC, Bergamaschi V, Castelli F; Migration Health Committee of the International Society of Travel Medicine. Forty meals for a drop of blood. J Travel Med. 2009; 16(1): 64-5.
6. Behere PB, Natraj GS. Dhat syndrome: the phenomenology of a culture bound sex neurosis of the orient. Indian J Psychiatry. 1984; 26(1): 76-8.
7. World Health Organization (1992) International Statistical Classification of Diseases and Related Health Problems (ICD-10). Geneva: WHO.
8. De Silva P, Dissanayake SAW. The use of semen syndrome in Sri Lanka: A clinical study. Sex Marital Ther. 1989; 4:195-204.
9. Malhotra HK, Wig NN. Dhat syndrome: a culture-bound sex neurosis of the orient. Arch Sex Behav. 1975; 4(5): 519-28.
10. Angst J, Gamma A, Gastpar M, et al. Depression Research in European Society Study. Gender differences in depression. Epidemiological findings from the European DEPRES I and II studies. Eur Arch Psychiatry Clin Neurosci. 2002; 252(5): 201-9.
11. Singh G. Dhat syndrome revisited. April 1985;27(2):119-122
12. Carroll BJ. Adolescents with depression. JAMA. 2004 Dec 1;292(21):2578
13. Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders. An overview. J Social Psychiatry 1986; 2:403-25
14. Avasthi A, Jhirwal OP. The concept and epidemiology of Dhat syndrome. J Pak Psychiatry Soc. 2005; 2: 6–8.

1

Original Research Article

Title: Dhat syndrome and its association with sexual behavior and pyschiatric comorbidities in Indian males

Sahu R.N, MD (Psychiatry), Head and Professor,

Co- Authors:

1. Sharma V K, MD, WHO Fellow (USA), Head and Professor, Department of Medicine Gandhi Medical College, Bhopal, Madhya Pradesh, India
2. Ashutosh Kumar, Lecturer, Gandhi Medical College, Bhopal, Madhya Pradesh, India
3. Chintan Bavishi, Lecturer, Manipal University, Manipal, Karnataka, India
4. Balaji More, Assistant Professor, Krishna Institute of Medical Sciences, Karad, Maharashtra

Title: Dhat syndrome and its association with symptoms, sexual behavior and comorbidities in Indian male patients


Abstract:

The Context (Background): Dhat syndrome is often taken as culture bound syndrome of Indian subcontinent. There are many misconceptions which form base of symptoms and comorbidities.

Aims: Dhat syndrome is reported on basis of self diagnosis. The study aims to study associated symptoms, sexual behavior and comorbidities in Indian population.

Methods and Material: This cross-sectional and case-control study, was carried with help of trained local interviewers at Department of Psychiatry and Medicine, Gandhi Medical College (GMC), Associated Hamidia Hospital, Bhopal, India. Cases were compared to healthy matched controls. The study was conducted using clinical interview, physical examination and other necessary investigations like urine analysis and microscopy.

Results: Of the 50 cases and control, each, age group was 21 to 25 years (48%) and education upto12

^th

class (60%). 20% cases reported history of Masturbation. Extramarital or premarital sexual contact was found to have little significance on the syndrome. 76% of the patients met DSM-IV Diagnostic Criteria for Anxiety and 56% patients met for Depression. 23 patients (46.3%) were having a co-morbid somatic complains like bodyache, weakness and fatigue. Erectile dysfunction by 34% & Premature ejaculation by 8% was reported. In Urine routine analysis and microscope no oxalates or phosphates were noted.

Conclusions: Dhat syndrome is more common among low educated young population. Laboratory evidence of any pathological cause was not found. Contrary to popular belief, it had no direct correlation with masturbation and pre and extra marital sexual contact.

Key Words:

Dhat Syndrome, Semen, Sexual behavior, Somatic symptoms, Erectile Dysfunction

Introduction

Dhat syndrome is a Culture bound syndrome.

¹

But it has been mentioned in medical history and reported by population worldwide. The culture has profound impact on the mental status of an individual. According to International Classification of Diseases (ICD) – 10 had classified Dhat syndrome had been classified in both neurotic disorder (F48.8) and into culture specific disorder caused by ‘undue concern about the debilitating effects of the passage of semen.’ The cases are always self reported and they often report a set of symptoms. These vague somatic symptoms are fatigue / bodily weakness, headache, depression

³

, anxiety, loss of appetite, palpitation / tachycardia, guilt, poor concentration, forgetfulness.

²

Due to existing belief it is often associated as a result of masturbation and being sexually active outside marriage. The comorbidities include erectile dysfunction, premature ejaculation and impotence.

Patients reported semen loss in urine or involuntarily outside (spontaneously; while sleeping; during defecation; or while showering) of sexual relations.

⁴

A typical profile of Dhat Syndrome patient either is a young man, unmarried or recently married, less educated, and the one who holds strong traditional beliefs.

⁵

This category of disease involves mixed disorders of behavior, beliefs, and emotions which are of uncertain etiology and nosological status and which occur with particular frequency in certain cultures. The cultural belief and pattern associated with Dhat syndrome make it different from delusional disorder.

^{6, 7}

Material and Methods:

The study is a case-control cross sectional study, aimed to evaluate the symptoms, beliefs and comorbidities related to Dhat syndrome. The study and control group of 50 each was assessed.

The study was conducted at Gandhi Medical College (GMC), Associated Hamidia Hospital, Bhopal, India. Study group of 50 subjects was selected who had Dhat syndrome without any other organic disorder at OPD of Psychiatry Department. The control group of 50 patients was shortlisted from the Medicine Department. They were not diagnosed for Dhat syndrome and were matched with the case group in most aspects. Both groups were interviewed based on a structured interview.

Inclusion criteria:

Case group:

Complain of whitish discharge in the urine and associating it with symptoms and comorbidities

Fulfilled DSM-IV TR criteria apart

Consenting to clinical interview

Control group:

Inpatients who were not suffering from Dhat syndrome though they were suffering from other medical ailments

Matched in other aspects with the case group

Consenting to clinical interview

Exclusion criteria: Presence of

1. Genitourinary disorder
2. Testicular tumor
3. Varicocele
4. Organic sexual dysfunction
5. Pelvic inflammatory disease
6. Endocrine disorders
7. Spinal cord trauma

Ethics:

Institutional review board and ethical committee approval was taken from GMC, Bhopal, India. All periodic adverse event reports were reported to them and appropriate guidance was taken.

All interviewers were careful about ethical and legal considerations. All identification information including names, initials and hospital numbers were avoided to keep the patient details in anonymity. Written information consent after the details of the project were fully explained was obtained from all participants. There were no minors involved and hence no paternal consent involved in this study.

Statistics: The data was analyzed by using statistical tests of mean and standard deviation. (

P>0.005)

Results:

Dhat syndrome is prevalent in younger age group. Anxiety is most prevalent followed by depression. They are related to sexual symptoms as ejaculatory dysfunction, premature ejaculation and impotence. (Fig. 1) Patients associated Dhat syndrome as a direct result of excessive indulgence in sexual activity or masturbation or to nocturnal emissions. (Fig. 2) Dhat syndrome was prevalent in class of lower education, below class 12.

Routine biochemical and urine laboratory evaluation was conducted for all 100 participants.Other necessary investigations were carried out as per the requirement of the subjects to exclude organicity ( Sonography and Hormone Assay). None of the reports showed presence of oxalates or phosphates. A semen analysis founded out only 1 patient had azoospermia and 2 were having oligospermia.

Figure 1: Co-morbid conditions associated with patients in study group and control group

Figure 2: Sexual history of patients in study group and control group

Discussion

As a Culture bound syndrome, Dhat syndrome has been discussed for long time. Epidemiology and prevalence is noted in history of medicine all over the world.

^{1, 8}

The Dhat syndrome is not limited to Indian subcontinent. The origin of its name had a strong relationship with Indian culture, history and mythology.

^{9, 10}

Dhat Syndrome forms an important health problem and the magnitude is also very high. In view of this it needs a proper attention and sensitization amongst the healthcare providers for the proper treatment, counseling of these patients and referring them to related specialty. The patient presenting with Dhat syndrome is typically more likely to be recently married; of average or low socio-economic status (student, laborer or farmer by occupation), came from a rural area and belonged to a family with conservative attitudes towards sex.

¹¹

The exact pathophysiology of ‘Dhat syndrome’ is not known. The study demonstrated various other symptoms and morbidities being involved along with Dhat syndrome. The prevalence in relatively younger age group can be attributed to hormonal rush.

¹²

Majority of these individuals visited self-claimed sex specialists and traditional faith healers. The contact with these health providers not only strengthen their misconception and false beliefs, but also compel the patients to pay huge cost of investigations and drugs which are not only non-effective but also hazardous.

⁵

Among other studies the relationship between marital status or sexual contact outside marriage and Dhat syndrome is not discussed. This study establish contrary to the popular belief that no such cause-effect relationship exists. Dhat syndrome was most common among illiterate patients and less educated patients. There is a need for patient education and sex education in the eradication of syndrome.

^{13, 14}

The spread of disease in all age groups indicate towards the need of patient education about the disease in India. In many cases the syndrome is under diagnosed. In general, the deep-rooted misconceptions associated with anatomical and physiological aspects of sexuality are difficult to be correct with general counseling sessions.

The further work in this field is required to know: Whether Dhat is a Culture bound syndrome only in India? What is the pathophysiology behind it? Is there any relationship of it with depression, anxiety or other mental health disorder? Whether there is any relationship between puberty and Dhat syndrome.

Acknowledgement: We are thankful to all the interviewers who conducted data collection.

References

1. Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes: the story of Dhat syndrome. Br J Psychiatry. 2004; 184: 200-9.
2. Bhatia M.S, Jhanjee A, Kumar P. Culture bound syndromes- a cross-sectional study from India. European Psychiatry. 2011; 26:448
3. Dhikav V, Aggarwal N, Anand KS. Is Dhat syndrome, a culturally appropriate manifestation of depression? Med Hypotheses. 2007; 69 (3): 698.
4. Mehta V, De A, Balachandran C. Dhat syndrome: a reappraisal. Indian J Dermatol. 2009; 54(1): 89-90.
5. El Hamad I, Scarcella C, Pezzoli MC, Bergamaschi V, Castelli F; Migration Health Committee of the International Society of Travel Medicine. Forty meals for a drop of blood. J Travel Med. 2009; 16(1): 64-5.
6. Behere PB, Natraj GS. Dhat syndrome: the phenomenology of a culture bound sex neurosis of the orient. Indian J Psychiatry. 1984; 26(1): 76-8.
7. World Health Organization (1992) International Statistical Classification of Diseases and Related Health Problems (ICD-10). Geneva: WHO.
8. De Silva P, Dissanayake SAW. The use of semen syndrome in Sri Lanka: A clinical study. Sex Marital Ther. 1989; 4:195-204.
9. Malhotra HK, Wig NN. Dhat syndrome: a culture-bound sex neurosis of the orient. Arch Sex Behav. 1975; 4(5): 519-28.
10. Angst J, Gamma A, Gastpar M, et al. Depression Research in European Society Study. Gender differences in depression. Epidemiological findings from the European DEPRES I and II studies. Eur Arch Psychiatry Clin Neurosci. 2002; 252(5): 201-9.
11. Singh G. Dhat syndrome revisited. April 1985;27(2):119-122
12. Carroll BJ. Adolescents with depression. JAMA. 2004 Dec 1;292(21):2578
13. Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders. An overview. J Social Psychiatry 1986; 2:403-25
14. Avasthi A, Jhirwal OP. The concept and epidemiology of Dhat syndrome. J Pak Psychiatry Soc. 2005; 2: 6–8.

1